Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens

Comparative Analysis of Bilateral Open Inguinal Hernia Repair and Rives-Stoppa Repair: A Comprehensive Review

Inguinal hernias present a significant healthcare burden globally, necessitating effective surgical management. This comprehensive review evaluates two primary surgical techniques for managing bilateral inguinal hernias: bilateral open inguinal hernia and Rives-Stoppa repair. This review aims to provide insights into optimal surgical approaches through a comparative analysis of these techniques, including examining advantages, disadvantages, outcomes, and factors influencing technique selection. Bilateral open inguinal hernia repair offers simplicity and familiarity, while Rives-Stoppa repair may provide advantages such as reduced recurrence rates and postoperative complications. The findings underscore the importance of considering patient-specific factors, surgeon expertise, and hospital resources when selecting the optimal approach. Further research is warranted to conduct long-term comparative studies and explore innovations in surgical techniques and materials, ultimately enhancing patient outcomes and advancing inguinal hernia repair practices.

Intradermal methylene blue analgesic application in posthemorrhoidectomy pain management: a randomized controlled trial

Introduction

Unbearable post-hemorrhoidectomy pain is a well-documented challenge, significantly impacting patient well-being and satisfaction after surgery, often influencing patients to decline in undergoing this procedure. It is widely recognized that methylene blue has an effect of reducing inflammation and pain by reduces the production of nitric oxide and inhibiting the action potentials production in nerves. This study aims to explore the potential benefits of postoperative regional administration of methylene blue in providing extended relief from post-hemorrhoidectomy pain.

Methods

This study included 97 patients aged 18-75 undergoing hemorrhoidectomy for stage III or IV hemorrhoids. A double-blind, randomized controlled trial compared postoperative intradermal injections of 1% methylene blue to 0.5% Marcaine as the control group. Two-week follow-up assessed pain. Statistical analysis, adherence to ethical standards, and registration were conducted.

Result

No significant differences were found in baseline demographics, surgical parameters, or complications between the Methylene Blue and control groups. Intervention group remained lower in mean pain score until the 12th day. Methylene blue group reported significantly lower postoperative pain scores from days 1 to 7, with no significant differences afterward.

Conclusion

This ongoing randomized controlled trial reveals the potential analgesic benefits of intradermal injection 1% methylene blue. It demonstrates comparable efficacy in reducing post-hemorrhoidectomy pain, with negligible side effects and complications.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital

PURPOSE

This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital.

METHODS

After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary.

RESULTS

A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005.

CONCLUSION

Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.

Age-Related Variations in Postoperative Pain Intensity across 10 Surgical Procedures: A Retrospective Study of Five Hospitals in South Korea

Age-related differences in pain perception have been reported in various contexts; however, their impact on postoperative pain intensity remains poorly understood, especially across different surgical procedures. Data from five hospitals were retrospectively analyzed, encompassing patients who underwent 10 distinct surgical procedures. Numeric rating scale scores were used to assess the worst postoperative pain intensity during the 24 h after surgery. The multivariate linear regression model analyzed the relationship between age and pain intensity. Subgroup analyses were performed according to sex and patient-controlled analgesia (PCA). This study included 41,187 patients. Among the surgeries studied, lumbar spine fusion (β = -0.155, p < 0.001) consistently and significantly exhibited a decrease in worst postoperative pain with increasing age. Similar trends were observed in cholecystectomy (β = -0.029, p < 0.001) and several other surgeries; however, the results were inconsistent across all analyses. Surgeries with higher percentages of PCA administration had lower median worst-pain scores. In conclusion, age may affect postoperative pain intensity after specific surgeries; however, a comprehensive understanding of the complex interplay between age, surgical intervention, and pain intensity is required. Pain management strategies should consider various factors, including age-related variations.

Analysis of characteristic features in ultrasound diagnosis of fetal limb body wall complex during 11-13+6 weeks

BACKGROUND

Limb body wall complex (LBWC) is a fatal malformation characterized by major defects in the fetal abdominal or thoracic wall, visceral herniation, significant scoliosis or spina bifida, limb deformities, craniofacial deformities, and umbilical cord abnormalities (short or absent umbilical cord). Early diagnosis of this condition is of great clinical significance for clinical intervention and pregnancy decision-making. With the rapid development of fetal ultrasound medicine, early pregnancy (11-13⁺⁶ wk) standardized prenatal ultrasound examinations have been widely promoted and applied.

AIM

To explore the value of prenatal ultrasound in the diagnosis of fetal LBWC syndrome during early pregnancy.

METHODS

The ultrasonographic data and follow-up results of 18 cases of fetal LBWC diagnosed by prenatal ultrasound during early pregnancy (11-13⁺⁶ wk) were retrospectively analyzed, and their ultrasonographic characteristics were analyzed.

RESULTS

Among the 18 fetuses with limb wall abnormalities, there were spinal dysplasia (18/18, 100%), varying degrees of thoracoschisis and gastroschisis (18/18, 100%), limb dysplasia in 6 cases (6/18, 33%), craniocerebral malformations in 4 cases (4/18, 22%), thickening of the transparent layer of the neck in 5 cases (5/18, 28%), and umbilical cord abnormalities in 18 cases (18/18, 100%), single umbilical artery in 5 cases.

CONCLUSION

Prenatal ultrasound in early pregnancy can detect LBWC as early as possible, and correct prenatal evaluation provides important guidance value for pregnancy decision-making and early intervention.

Influence of the learning curve on the immediate postoperative pain intensity after laparoscopic inguinal hernioplasty

Introduction

Inguinal hernia repairs represent one of the most commonly performed surgical operations worldwide. As more experience has been gained over the past decades with laparoscopic techniques, they are now widely used also for the repair of primary and unilateral inguinal hernias, representing a safe and effective alternative. One of the major concerns of patients undergoing inguinal hernia repair is postoperative pain and socio-professional reintegration.

Aim of study

This study started from the hypothesis that the learning curve could influence postoperative pain intensity after laparoscopic inguinal hernioplasty.

Methods

A retrospective - comparative study was performed, including a general surgeon's first consecutive cases (n=87) of TAPP (transabdominal preperitoneal procedure) hernioplasty procedures with implantation of self-gripping surgical prosthesis were investigated.

Results

The evaluation of clinical and surgical aspects resulted in similar values in case of the studied groups. A reduction in surgical time was observed in case of patients operated after completing the learning curve (p = 0.0005) On the first postoperative day patients complained mostly about persistent and severe type of pain. Average Pain Index calculated with help of Simple Numeric Pain Scale resulted in similar values. Length of analgesic treatment showed no significant differences. Although higher intensity pain was mostly caracteristic in case of patients operated during the learning process, no significant relationship between learning curve and postoperative pain intensity were highlited.

Conclusion

TAPP can be a safe technique for young surgeons as well, with the right study program the procedure can be mastered safely.

A Rare Case of Inguinal Hernia of a Ureter Belonging to a Duplex Kidney

Introduction

Inguinal herniation of the ureter is a rare entity that occurs either as a complication of renal transplantation or spontaneously. Patients may suffer from obstructive uropathy or groin pain due to the unusual ectopic course of the ureter. This case report highlights the importance of recognizing a ureteroinguinal hernia.

Methods

In this case report, we present a 75-year-old man with a surgical history of a right inguinal hernia repair who was referred to our center with burning left inguinal pain that persisted for two weeks. The patient's history and physical examination were consistent with an inguinal hernia. The suspected indirect inguinal hernia was found on preoperative imaging to be a tubular structure distinct from the intestine or adjacent organs. An open exploration of the inguinal canal was performed to prevent further hernia development.

Results

The unusual structure in the inguinal canal turned out to be an ectopic ureter originating from the left upper pole moiety of the left duplex kidney (i.e., with duplicated ureters) and containing concentrated urine, as confirmed on a postoperative computerized tomography urogram.

Conclusion

It is crucial to perform a thorough clinical examination and utilize adequate imaging modalities before surgical procedures when encountering unidentified structures.

Body Mass Index Within Multifactor Predictors of Ventral Hernia Recurrence: A Retrospective Cohort Study

Background A ventral hernia is a protrusion of the peritoneum through the defective abdominal wall. Several risk factors increase the likelihood of hernial recurrence. One of the most common risk factors is obesity, defined by the World Health Organization (WHO) as increased body mass index (BMI). Few studies have explored the effects of BMI and other factors on hernia recurrence. Hence, we aimed to investigate the role of increased BMI in hernia recurrence in conjunction with various risk factors such as age, sex, type of hernia, the time elapsed between the occurrence and recurrence, complications of hernia, and procedure. Methods This retrospective cohort study was conducted at King Abdulaziz University Hospital (KAUH). All the patients were admitted between 2015-2022. A total of 1676 medical records were obtained from all patients who underwent hernia repair more than once or were diagnosed with a recurrent hernia during the study period. Results Our study revealed an insignificant correlation between a BMI of more than 25 kg/m² and the recurrence of inguinal hernias, predominantly indirect hernias. Furthermore, overweight and obese patients experience a longer interval between the first and second hernia repairs. Interestingly, all the patients with inguinal and umbilical hernias had the same diagnosis at the second presentation. However, the findings also included a significant increase in umbilical hernias in individuals with a high BMI and higher recurrence rates among male patients with inguinal hernias. Conclusion BMI higher than 25 kg/m² increases recurrence rates for umbilical hernias but decreases the recurrence of inguinal hernias.

Return to Work in Patients With Unilateral Inguinal Hernia Surgery: A Comparative Study Between Laparoscopic Transabdominal Preperitoneal Approach and Lichtenstein Tension-Free Mesh Repair

Objective The objective of this prospective cohort study was to compare the time to return to work between patients who underwent laparoscopic transabdominal preperitoneal (TAPP) hernia repair and those who underwent Lichtenstein tension-free hernia repair with mesh for unilateral inguinal hernia. Methodology Patients were registered for unilateral inguinal hernia review at Aga Khan University Hospital, Karachi, Pakistan, from May 2016 to April 2017 and followed till April 2020. All patients aged 16-65 planned for unilateral transabdominal preperitoneal hernia repair or Lichtenstein tension-free hernia mesh repair were included. Patients with bilateral inguinal hernia repair, limited activity, or above retirement age were excluded. A non-probability consecutive sampling technique was implemented, and patients were divided into two cohort groups: Group A underwent laparoscopic transabdominal preperitoneal hernia repair, while Group B underwent Lichtenstein tension-free mesh repair. Patients were followed up at one week to inquire about the resumption of activities and then at one and three years for recurrence. Results Sixty-four patients met the inclusion criteria; three patients opted out of research, and 61 patients agreed to participate; one patient was excluded due to the conversion of the procedure. The remaining 30 in Group A and 30 in Group B were followed for the study period. The mean time to return to work in Group A was 5.33 ± 4.46 days; in Group B, it was 6.83 ± 4.58 days, with a p-value of 0.657. One recurrence was observed at three years in Group A. Conclusion Although the time to return to work at our hospital was slightly shorter in laparoscopic hernia repair than in the open technique, the results were not statistically significant. In addition, there was no significant difference in hernia recurrence at the one-year follow-up between laparoscopic transabdominal preperitoneal hernia repair and Lichtenstein tension-free hernia mesh repair for unilateral inguinal hernia.

A Rare Case of Amyand's Hernia

A hernia is an abnormal protrusion of an organ or tissue from its containing cavity. The most common type of abdominal hernia is an inguinal hernia. When a hernia is non-reducible, it is termed an incarcerated hernia. We present one such rare case of an incarcerated appendix within a right inguinal hernia, also called Amyand's hernia (AH). We discuss current approaches toward surgically repairing this type of complicated hernia and a complication that can arise if it is not repaired in a timely manner.

Component Separation: A Case Report of Hybrid and Synthetic Absorbable Mesh Use for Complex Large Ventral Hernia Reparation

Ventral abdominal hernias are a common abdominal wall defect in the United States. We present a 50-year-old Caucasian male with a large (>18 cm) abdominal wall defect. An extensive complex abdominal wall reconstruction with advanced bilateral fascial flaps/component separation and repair of the abdominal wall defect was planned to restore the appropriate abdominal wall anatomic contour. The use of double mesh in large abdominal wall defects is still a relatively new documented technique. Only two case series detail the same technique used on this patient, with no articles on using a hybrid mesh with a synthetic absorbable mesh. This case uses an underlay and onlay mesh technique, with a hybrid mesh, Tela Biologics (Malvern, PA, USA), under the muscle, in this case, intraperitoneal bridging the gap. The anterior rectus sheath was reinforced with intercepted 0-Ethibond sutures (Ethicon/J&J, Bridgewater, NJ, USA) and then reinforced with a synthetic absorbable mesh (Phasix^TM, Becton Dickinson, Franklin Lakes, NJ). The outcome with this patient shows more research should be conducted on considering long-term results with the types of mesh and the question of whether there are additional benefits when using two different types of mesh and their placement in the sandwich technique.

A Rare Case of Left Inguinoscrotal Hernia Containing Stomach

This is the case of a 71-year-old male who presented to the emergency department with the chief complaint of left inguinoscrotal swelling and pain. The patient stated that he had nausea, vomiting, and constipation for a few weeks prior to the presentation. He also reported that he had a reducible, asymptomatic left inguinal hernia for the past 20 years. He began to experience pain in the left groin related to the hernia recently. During the past two weeks, he was having liquid bowel movements, and his last bowel movement occurred the morning of presentation. The patient did not report any fevers, chills, shortness of breath, or chest pain. His physical examination was remarkable for left lower quadrant fullness and mild abdominal distension. A large incarcerated left inguinoscrotal hernia was present, which markedly displaced and engulfed his penis. The patient was taken to the operating room for open inguinal hernia repair with mesh, where stomach and small bowel were encountered within the hernia sac. There was no ischemia noted, thus we repaired the hernia with mesh. The patient tolerated the procedure well and progressed postoperatively without incident. He was successfully discharged on postoperative day one. This case and literary review is a reference to the practicing general surgeon treating an incarcerated hernia containing the stomach.

Intrathecal Co-administration of Morphine Facilitated the Anti-nociceptive of Bupivacaine in a Rat Model of Acute Postoperative Pain

Introduction: Bupivacaine is one of the commonly used agents for spinal anaesthesia. Moreover, co-administration with morphine can likely increase its anti-nociceptive effect bringing about a reduction in the required dose of bupivacaine. Though this has been observed clinically, preclinical studies on the efficacy of this drug combination are lacking.

Methods: Sprague Dawley rats, previously implanted with intrathecal catheters, were administered either bupivacaine (30 mcg) or morphine (30 mcg) or both bupivacaine and morphine (15 mcg each). These doses were determined following prior evaluation of different doses of bupivacaine (3, 10 and 30 mcg). Rats were subjected to hind paw incision under isoflurane anaesthesia, 15 min after drug administration. Anti-nociception was evaluated by estimating mechanical allodynia in a fixed peri-incisional area using von Frey filaments. This was done 4 h after the incision.

Results: Both bupivacaine and morphine attenuated allodynia though morphine was more effective. Co-administration of both drugs at half the doses increased the antinociceptive effect of bupivacaine to the 30 mcg dose level.

Conclusion: The underlying reason for this enhanced anti-nociception could be the different neural mechanisms responsible for anti-nociception. Local anaesthetics inhibit the generation of action potentials by blocking sodium channels whereas opioids like morphine act through G-protein coupled mu opioid receptor-linked closure of calcium channels in presynaptic terminals. In conclusion, the addition of morphine can facilitate bupivacaine’s anti-nociceptive effect following intrathecal administration. This information could have clinical relevance in the treatment of postoperative pain.

Surgeon's Impact on Opioid Epidemic Following Uncomplicated Laparoscopic Appendectomy and Cholecystectomy

The opioid crisis in the United States remains a major issue that is directly linked to the prescribing practices of physicians. There is a lack of consistency in post-operative prescribing of narcotic medications. We have designed a retrospective study to evaluate factors that contribute to the prescription of opioids following common laparoscopic procedures. In this study, we analyzed peri-operative medications and pain requirements and how they relate to the frequency in which narcotics are prescribed at Saint Joseph’s University Medical Center (SJUMC), a level two trauma center and teaching hospital. We also studied how the frequency of narcotic prescriptions is related to patient demographics and surgeon practices. We propose that standardizing pain medication protocols will be an effective way to decrease overall narcotic use as well as prescriptions for common laparoscopic procedures.

Analgesic effect of paracetamol monotherapy vs. the combination of paracetamol/parecoxib vs. the combination of pethidine/paracetamol in patients undergoing thyroidectomy

INTRODUCTION

The purpose of this study was to investigate the analgesic effect of 3 different regimens of combination analgesics administered to patients undergoing thyroidectomy.

MATERIAL AND METHODS

A total of 152 patients undergoing total or subtotal thyroidectomy were enrolled. Patients allocated to group A received a combination of intravenous (IV) paracetamol and intramuscular (IM) pethidine, patients in group B received a combination of IV paracetamol and IV parecoxib, while patients in group C received IV paracetamol monotherapy.

RESULTS

The analgesic regimens of groups A and B were found to be of equivalent efficacy (p-value = 1.000). In contrast, patients in group C (paracetamol monotherapy) had higher numerical rating scale scores, compared to both patients in groups A (p-value < 0.001) and B (p-value < 0.001).

CONCLUSIONS

The combinations of IV paracetamol with either IM pethidine or IV parecoxib are superior to IV paracetamol monotherapy in achieving pain control in patients undergoing thyroid surgery.